Create a Universal Reimbursement Rate/Structure

BHST Part One: Performance and Value - Based Contracting

This section focuses on the progress and lessons learned in identifying Public and Private Payers to braid funding together and to establish a proof of concept contract for services.E

As part of the initial work toward System Assessment & Capacity Building for Clinical & Financial Design, Baseline knowledge of local key Provider Organizations and Providers currently operating in Orange County coupled with information about approach and experiences from related transformation efforts in systems across California and the country obtained helped to inform the ongoing exploration work in Orange County. Work toward identifying available funding streams and applicable State and Federal rules/regulations continues to be closely linked to planning work for California Advancing and Innovating Medi-Cal (CalAIM). CalAIM is a multi-year initiative by DHCS to improve the quality of life and health outcomes of the population by implementing broad delivery system, program, and payment reform across the Medi-Cal program. Orange County continues to be a very active participant in the planning for CalAIM. In addition to these activities, Orange County is working with Mind OC to analyze the funding sources and allocations across directly operated and contracted behavioral health programs and services.

Available funding streams across the public and private sector vary within Orange County and are in flux with everchanging State and Federal rules, regulations, and policy changes. Throughout this reporting period, Mind OC noted the following learnings.E Early lessons learned related to available funding streams and State and Federal rules/regulations highlight the need to broaden the scope of inquiry to address the need for specialty behavioral health to be clinically, administratively, and financially structured to support physical health just as primary care and other physical health services need to be structured to support behavioral health. Several factors were consistently identified as central barriers or complications:

The specialty behavioral health carve out managed by the counties and the mild-tomoderate behavioral health/physical health benefit administered by (generally) Medi-Cal health plans

Cost based reimbursement centered on units of services delivered, and the current inability to pay any sort of “bonus” that exceeds actual costs incurred

MHSA funding is unique to California, adding an additional complicating factor, especially in light of how deeply intertwined these funds have become with Medi-Cal services

Measurement efforts regarding behavioral health service outcomes tend to be overly complex (e.g., DLA-20) or overly simplistic (e.g., follow-up after emergency department visit or hospitalization for mental illness) and there is no standard level of care measure that is used consistently in CA These barriers and complications are not new, and continually revealed to be inextricably linked to efforts to identify available funding streams and State and Federal rules/regulations.

Several areas of opportunity for Orange County’s BHST work continues to be a focus through the course of this work:

CalOptima, created by the Orange County Board of Supervisors in 1993 as a County Organized Health System (COHS), manages Medi-Cal services for the entire county, and only for Orange County. Compared to many other areas in CA with more complex health plan arrangements (e.g., the COHS spans multiple counties and associated Boards of Supervisors, the county is served by multiple Medi-Cal managed care plans, etc.), moving toward a more aligned, payer agnostic system of care can be a more focused partnership between the County and Cal-Optima. The collaborative potential of strong and aligned leadership at Orange County’s Health Care Agency, Behavioral Health Services, CalOptima, and Mind OC was regularly noted, as was the strong potential embodied in the broader Be Well movement and a supportive Board of Supervisors Key Informants highlighted the relative simplicity of the Orange County health care delivery system, in comparison to other counties, regions, and states, with Orange County services being largely limited to behavioral health, with exceedingly limited directly provided physical health care services (as opposed to having a county operated FQHC or hospital) Related transformation efforts offer many lessons and opportunities from the activities that have already been undertaken in California and Orange County, to say nothing of across the nation, and the coming transformation envisioned in CalAIM. Several of these past initiatives, such as Whole Person Care, Drug Medi-Cal Organized Delivery System, and Health Homes offered insight into project activities.